CLINICAL RECORDS

Information Needed to Conduct Clinical Record Search
Records not in the Patient Index Retrieval System
Records in the Patient Index Retrieval System
Records at the Civilian Personnel Records facility
Other Things to Know

Seldom does a veteran know to ask for a “clinical” record.  Because few veterans make a distinction between ‘inpatient’ and ‘outpatient’ records, and because few know that clinical records and health records are retired separately to NPRC, the veteran often asks only for medical records.  Do not make a clinical search in response to every request for medical records.

However, if a requester asks for records of surgery or treatment for a serious illness or injury (e.g., hepatitis, broken back, etc.), or if veteran says he was wounded in action or involved in an auto accident, or if a veteran writes a second time for his/her medical records and says “you didn’t send me all my records,” THINK CLINICAL RECORD(S).

NOTE:  Military personnel and their dependents can be treated at medical facilities of other branches of service, as well as their own services facilities. Clinical records for dependents treated at an Air Force or Army facility are stored at CPR. Clinical records for dependents treated at Naval facilities are stored at this facility (MPR).  CPR does not maintain any clinical records for veterans.

1) Patient’s name and status when treated (i.e., service member, dependent, retiree)
2) Social security number, and/or service number of member/sponsor
3) Type of record (inpatient or outpatient)
4) Date(s) and place(s) of treatment
5) Nature of illness, injury, or treatment*

*This data is not needed if clinical records are in the Patient Index Retrieval System (PIRS).  But it could be helpful in locating records of treatment prior to:

 1971 for Air Force
 1970 for Army
 1965 for Navy

Treatment at an Air Force facility between 1951* and 1971
Treatment at an Army facility between 1955* and 1970
Treatment at a Navy facility before 1965

Prepare ORU search request on NA Form 13105, NPRC Search Request and Reply, providing all info, as shown above, required to conduct a search of clinical records.  If the veteran does not provide enough information for an OR search:

1) Examine military record for any clinical record summaries, old VA Forms 3101, or previous requests that may provide additional information to conduct a search.
2) If information provided is insufficient, SEND requester an NA Form 13042, Request for Information Needed to Locate Medical Records.

* Special Note regarding Clinical Record Libraries:

Air Force:  The Air Force began retiring clinical records separately from the OMPF’s in 1957;  However, if the retiring facility was classified as a “Clinical Record Library” (CRL), then the date of earliest retirement could go back as far as 1951.  So before a negative reply is given, ensure that treating facility was not a CRL.

Army:  The Army began retiring clinical records separately from the OMPF’s in 1960;  However, if the retiring facility was classified as a “Clinical Record Library” (CRL), then the date of earliest retirement could go back as far as 1955.  So before a negative reply is given, ensure that treating facility was not a CRL.

A list of Clinical Record Libraries is found in NPRC 1865.121, Appendix 2-D.

Not all hospitalizations were entered in the PIRS database.  Admissions shown in the PIRS may not be on file at this Center, and conversely, if the PIRS is negative, it does not mean an individual was not hospitalized.  The PIRS is an extremely valuable tool to provide assistance to us in locating clinical records, but an actual OR search of the retired clinical records must be conducted before any final determinations or decisions can be made as to the actual location of the record.

Treatment at an Air Force facility after 1971
Treatment at an Army facility after 1970
Treatment at a Navy facility after 1964
Dependent treated at Naval facility

Probe the Patient Index Retrieval System (PIRS) by entering the service member´s social security number and service number, if veteran had one.  The PIRS printout will show:  (1)  patient registry number for each clinical hit; (2)  family member prefix (FMP); (3)  date of admission/ treatment [could be shown as month/day/year, or month/year, or day/year, or Julian date]; and (4)  place of treatment.  Enter your charge-out information, and SEND to ORU.  Prepare a separate PIRS printout for each clinical search.

FAMILY MEMBER PREFIXES (FMPs) ON PIRS PRINTOUT

1-19     Child of service member
20        Service Member
30        Spouse of service member

See NPRC 1865.121 for additional FMP listings.  If the PRS printout shows an FMP number not on the listing, compare date and place of treatment on printout to information furnished by veteran to determine if the PIRS hit might pertain to veteran.

NOTE:  A positive PIRS printout does not mean a record is actually at NPRC.  Submit request to OR.  If the clinical record has not yet been retired to NPRC, the OR Section should give you the hospital’s address, which you should provide to the requester.

Dependent treated at Air Force or Armyfacility

Notify requester of DELAY.

The earliest Navy clinicals at NPRC date back to 1940s.

In addition to inpatient (clinical) records, OR also maintains the outpatient records of military dependents and retirees.

Medical records of military dependents and retirees are filed according to the year and place of treatment.  The records, compiled over the years, may be combined in one folder and then retired to this Center by the last medical facility at which the individual was treated.  It is also possible that the records are filed in several locations.  If a request contains insufficient information to make an OR search, SEND the requester an NA Form 13042.

Source:  NPRC 1865.121 and NPRC 1865.103